Healthcare Provider Details

I. General information

NPI: 1902146368
Provider Name (Legal Business Name): KELLY LYNN BRODSHO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 BROADWAY N
FARGO ND
58102-1420
US

IV. Provider business mailing address

2800 BROADWAY N
FARGO ND
58102-1420
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-0221
  • Fax: 701-241-7944
Mailing address:
  • Phone: 701-293-0221
  • Fax: 701-241-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4301
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: